Chest Pain

Jessica Hernandez

Jarone Lee

Introduction

Chest pain accounts for 10% of visits to the emergency department (ED).
Etiologies of chest pain range from life threatening to benign.
Forty-five percent of patients with chest pain are eventually diagnosed with acute coronary syndrome.
- Of these, 7% are younger than the age of 35, and 50% are older than the age of 40.
Noncardiac causes of chest pain include:
- GI disease – GERD/reflux, esophageal spasm, peptic ulcer disease, biliary colic, pancreatitis, bowel obstruction.
- Respiratory – pulmonary embolus, pneumonia, pneumothorax, pleurisy, empyema.
- Chest wall syndromes – shingles, soft tissue injuries, rib fracture.
- Nerve root compression.
- Psychiatric – anxiety, globus, panic disorders, somatization.
Musculoskeletal pain accounts for 36% of chest pain complaints, of which 13% are due to costochondritis.

Pathophysiology

Chest pain is frequently described as the following:
- Tightening, burning, pressure, aching, sharp, tearing, or gaseous.
Chest pain sensation from visceral organs (esophagus, heart, lung, great vessels, etc.) arise from the same autonomic ganglia.
Painful stimuli felt in the chest can refer throughout the torso, neck, and upper extremities.
No one description of chest pain can be definitively correlated with a specific cause.

Cardiovascular Chest Pain

Cardiac Ischemic Pain (Acute Coronary Syndrome)

Cardiac ischemia is due to an inability to meet oxygen and nutrient demands.
- Atherosclerosis is the leading cause of coronary vessel narrowing, which leads to ischemia.
- Management:
  - Percutaneous coronary intervention (PCI) is the management of choice for patients with ST elevation myocardial infarction (MI). In centers without these capabilities, thrombolytics are an option as long as there are no contraindications.
  - Other management options include:
    - Aspirin – shown to improve mortality with a number needed to treat of 42.
    - Pain control can be achieved with narcotic analgesia and nitrates.
    - Other options have shown no benefit in mortality but are utilized: clopidogrel, glycoprotein IIb/IIIa inhibitors.
Cocaine-induced chest pain is caused by vasoconstriction of the coronary arteries due to its direct alpha agonist effects. However, it is also known to accelerate atherosclerotic disease.
- Management:
  - PCI is the management of choice for patients with signs of ischemia by Electrocardiogram (EKG) and cardiac markers.
  - Aspirin.
  - For pain control, consider benzodiazepines, opiates, or nitroglycerin.

Pericardial Pain

Pericardial pain is caused by inflammation of the pericardial sac (pericarditis).
Sudden sharp pain that worsens when supine and with inspiration.
Look for EKG findings or presence of a pericardial rub.
EKG stages:
- Stage 1 – diffuse ST elevations with PR segment depression.
- Stage 2 – normalization of ST and PR changes; flattening of the T waves.
- Stage 3 – diffuse T wave inversions.
- Stage 4 – normalization of EKG, or may continue to have persistent T wave inversion.
Due to its intimate anatomical relationship, myocarditis may also present similarly.
Etiology includes:
- Neoplastic.
- Autoimmune.
- Infectious – TB, other bacteria, viral.
- Uremia.
- Post-MI.
- Idiopathic.
Management:
- NSAIDs are the treatment of choice for these patients.
- Definitive treatment is varied and should focus on the underlying cause.